Chest X-Ray breakdown: how to deal with multiple cavitating lung lesions
A gentleman in his 80s presents with a few month history of weight loss and fatigue. What do you think about his Chest X-Ray? What is the differential diagnosis?
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MULTIPLE CAVITATING LESIONS
👨🏽💻The key to assessing this X-Ray is to recognise the presence of ‘cavitation’ within several of the lung lesions. Once you see this, the differential changes somewhat compared with if you saw regular lung nodules
👨🏽💻With a single cavitating lung lesion, the main differential is between infection (including TB) and primary lung cancer (commonly squamous cell). With multiple lesions we open the differential out a bit using the mnemonic STARE:
Squamous cell metastases (most common metastases that cause cavitation)
TB and other infection
ANCA positive vasculitis
Rheumatoid nodules
septic Emboli
👨🏽💻 As always the clinical picture will help us move between the different possibilities. Here there is an abnormality of the mediastinum which can point us more towards cancer and infection
👨🏽💻In this case it took a groin node biopsy to get to the final diagnosis: metastatic disease from a neuroendocrine tumour which isn’t a common cause for cavitating lung lesions. The key to tackling these cases is to recognise the cavitating lesions then using the STARE differential see which fits the clinical picture best
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